UI Challenge Course Registration Form

Organization or Group Name

Affiliation with the University of Iowa

UI Student Group/Organization

UI Faculty, Staff, or Department

Not affiliated with the University of Iowa

Contact Person

Mailing Address

City, State, Zip

Phone Number

Email Address

Program Preference

Half Day- Low elements only (3-4 hours)

Half Day - low and high elements (4 hours)

Full Day - low and high elements (6-8 hours)

Preferred Event Date and Time

Second Preferred Event Date and Time

Third Preferred Event Date and Time

Anticipated number of participants (12 participant minimum charge)

Participants with special needs

Reason for event

Please choose three areas you would like to focus on:

Communication

Respect

Confidence

Exploring Diversity

Conflict Resolution

Play/Fun

Teamwork

Problem-Solving

Trust

Billing Person (if different from above)

Billing Address (if different from above)

Billing Email Address (if different from above)

Billing Phone Number (if different from above)